Tri-Service Medical Information Symposium...

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Tri-Service Medical Information Management Symposium.

http://www.surveygizmo.com/s3/789671/tmims

Tri-Service Medical Information Symposium 2012

http://www.surveygizmo.com/s3/789671/tmims

The Integrated Electronic Health Record, Virtual Lifetime Electronic Record and Data

Sharing

Briefing to Tri-Service Medical Information Management Symposium

February 19, 2012

Conflict of Interest Disclosure

Mary Ann Rockey, SES Program Executive Officer, Joint Medical Information Systems/Clinical

Military Health System

COL Joseph Grebe, AQ, USA iEHR Program Manager (DoD)

DoD/VA Interagency Program Office

Susan Perez, SES iEHR Program Manager (VA)


Douglas Rosendale, DO, FACOS Director, Clinical Informatics (VA)


CAPT Michael Weiner, DO, MSM, MSIST, USN Director, Clinical Informatics (DoD) DoD/VA Interagency Program Office

2

Learning Objectives

• Describe existing health data sharing initiatives that support improved healthcare delivery

• Explain the direction from the Secretaries of Defense and Veterans Affairs to pursue a joint, common platform that will allow a seamless transition of a Service member's medical information between the military healthcare system and the Veterans Affairs healthcare system

• Describe the synergies and common business processes already identified, including common data standards and data center consolidation, common clinical applications, and a common user interface

3

Agenda

• Current Electronic Health Record (EHR) Systems

• Current health data sharing

• What’s next for EHR

4

Current EHR Systems

• Working to maximize speed, availability, and usability of the current EHR

• Supporting legacy systems to ensure timely access to and use of clinical systems

• AHLTA

• Essentris

• Composite Health Care System (CHCS)

• AHLTA-Theater

• Theater Medical Information Program CHCS Cache

(TC2)

• Theater Medical Data Store (TMDS)

5

Current* Health Data Sharing

6

VA

• 92.7 million lab results

• 15.0 million radiology reports

• 95.7 million pharmacy records

• 113 million standard ambulatory data records

• 5.2 million consultation reports

• 3.3 million deployment-related health

assessments on more than 1.5 million individuals

• 4.3 million correlated patients, including

1.9 million patients not in FHIE repository

• 148,140 average weekly FHIE/BHIE queries

1st qtr FY 2012

• Computable pharmacy and allergy exchange

on more than 1,338,750

DoD

Data on Separated Service Members • Outpatient pharmacy data, lab and radiology results

• Inpatient laboratory and radiology results

• Allergy data

• Consult reports

• Admission, disposition, transfer data

• Standard ambulatory data record elements

(including diagnosis and treating physician)

• Pre-/post-deployment health assessments

• Post-deployment health reassessments

Data on OIF/OEF Polytrauma Patients • Radiology images

• Scanned medical records

Data on Shared Patients • Current Viewable Data

– Outpatient pharmacy data, laboratory and radiology results

– Inpatient laboratory and radiology results

– Discharge summaries (58* DoD sites = 100% of inpatient beds)

– Inpatient consultations, operative reports, history and physical

reports, transfer summary notes, initial evaluation notes,

procedure notes, evaluation and management notes, pre-

operative evaluation notes, and post-operative evaluation and

management notes (58* DoD sites - available to all DoD

providers and VA providers enterprise wide)

– Allergy data and problem list data

– Theater clinical data: Theater inpatient notes, outpatient

encounters, and ancillary clinical data

– Ambulatory encounters, procedures, and vital signs

– Family, social, and other history, and questionnaires

• Current Computable Data (limited VA sites) – enables drug-drug

and drug allergy safety checks and alerts

– Pharmacy data

– Medication allergy data

* Walter Reed AMC & Bethesda NNMC merged to form WRNMMC in

Sept. 2011

Federal Health Information Exchange

Live data flow beginning 2002; data from 1989 forward

One-way, monthly transfer of health data

Bidirectional Health Information Exchange

Live data flow beginning 2004; data from 1989 forward

Two-way, on-demand view of health

data available in real-time

Health data on more than 5.8 million

Service members

All VA Medical

Facilities

5 VA Polytrauma Centers

(Tampa, Richmond, Minneapolis,

Palo Alto, San Antonio) One-way transfer of health data initiated

at time of decision to transfer patient

Viewable data exchange between all DoD

and VA medical facilities as of July 2007

From Walter Reed National Military

Medical Center in Bethesda and Brooke AMC

• Radiology images for more than 470 patients

• Scanned records for more than 570 patients Live data flow beginning March 2007

*As of Jan 2012

James A. Lovell Federal Health Care Center

7

December 2010

Fiscal Year 2011

Fiscal Year 2012 • Infrastructure

• Data Center

• Virtualization

• Enterprise Service Bus

• Build a Single Patient Registration process

• Create Medical Single Sign-On with

Patient Context Management

• Single Order Entry

process for

Laboratory

• Single Order Entry process

(orders portability) for

Radiology

• Single Graphical User

Interface (GUI)

Defer to iEHR • Pharmacy

Current Health Data Sharing

VLER Health -- Pilots

Six Month Increments

8


March 25, 2011

• Health Record Data: – HITSP C32 subset

(from Tidewater) – Vital Sign – Chemistry Lab Result

• Partners: – 92nd Medical Group,

Fairchild AFB – Spokane VA Medical

Center – Inland Northwest Health

System

Spokane Pilot

September 30, 2011

• Health Record Data: – HITSP C32 subset (from

Spokane) – Advance Directive * – Encounter – Immunizations* – Insurance Provider – Procedures – Unstructured

Documents: Consults/Referrals Discharge

Summaries Results of Diagnostic

Studies Procedure Notes History & Physicals

• Partners: – Madigan Army Medical

Center – VA Puget Sound Health

Care System – MultiCare Health Org

* will display but not send

Puget Sound Pilot

September 15, 2010

• Health Record Data: – HITSP C32 subset

(from San Diego) – Comment – Hematology Lab Result

• Partners: – Naval Medical Center

Portsmouth – VA Medical Center

Hampton – Med Virginia

Tidewater Pilot

November 16, 2010

• Additional Partners: – McDonald Army

Health Center

(MCAHC), Fort Eustis

– 633 Medical Group,

Langley AFB

January 31, 2010

• Health Record Data:

Healthcare Information

Technology Standards

(HITSP) C32 subset: – Allergy/Drug Sensitivity – Condition – Healthcare Provider – Information Source – Language Spoken – Medication – Person Information – Emergency Contact

• Partners: – San Diego VA Medical

Center – Naval Medical Center

San Diego – Kaiser Permanente in

San Diego

San Diego Pilot

VLER Health -- Provider Access via AHLTA

NOTE -- The health record

depicted here contains

sample test data used for

demonstration purposes

9


TRICARE Online and the DoD Blue Button

10

Initial Blue Button Capabilities (June 2010)

• View, download (.pdf), and print personal

health data

• Access outpatient medication profile

• Access allergy profile

Additional Patient Portal Capabilities (January 2011)

• Book unlimited number of appointments

• Access TRICARE benefits and general healthcare

information and services

• Access laboratory results, outpatient problem lists,

and outpatient encounter notes


EHR Milestones (1979 – 2011)

11

Oct 2011:

Secretary of Defense

and Secretary of VA

signed IPO Charter

What’s Next for EHR

12


iEHR -- Governance Structure

iEHR

Advisory

Board HHS (ONC),

National Health IT Task Force

DEPSECDEF / VCJCS

Secretary of Defense

DEPSEC VA

Secretary of

Veterans Affairs

Open Source

Custodial

Agent

BoD CEO

Community Gov./Oversight

Mainline Maint. & Extend

Test & Cert. Protocols

Distribution & Licensure

Bus. Process

Reengineering

Functional/Perf

Requirements

Data Standards & Compliance

Architectural

Requirements Clinical/Ops Workflow

Health

Executive

Council

iEHR Program

Executive

IV&

V /

Test

& E

valu

ati

on

Translation/CIIF

TBD

Data Centers

DoD - DISA

Common GUI

VA

Joint ESB

DoD

Innovation & Dev

Test Bed - TBD

Identity Mgmt

DoD- DMDC

CSB

TBD

Apps/Capabilities

DoD

Apps/Capabilities

VA

13


iEHR -- “To Be” Architecture

DoD Only VA Only Joint DoD/VA

Common Interface Standards

Common Interface Standards

Presentation (Common GUI)

Common Data Centers

Common Services Broker (includes Enterprise Service Bus (ESB) and Infrastructure Services)

Common Information Interoperability Framework (CIIF) Common Information Model, Common Terminology Model,

Information Exchange Specifications, Translation Service

Common Data Standards: SNOMED CT and Extensions, LOINC and RxNorm

Pharmacy

Disability

Evaluation

Dental Care

Personal

Health Record

Inpatient

Orders Mgmt

Consult &

Referral Mgmt Immunization

Laboratory

Emergency

Dept Care

Nursing

Home

Rehabilitative

Care

Long Term

Care

Transient

Outreach

DoD Unique VA Unique Common (Joint) Applications & Services Battlefield

Care Pediatrics

Military

Readiness Obstetrics

Enroute

Care Veterinary

Operating

Room Mgmt

Blood Mgmt

Document

Mgmt

Applications and Services

Common DoD-VA Requirements: HL7 EHR-S Functional Model with DoD and VA vetted Extensions (SV-4)

Common DoD-VA Integrated Health Business Reference Model (OV-5)

Common DoD-VA “To Be” Process Flow Model (OV-6C)

Common DoD-VA Measures of Effectiveness, Measures of Performance and Key Performance Parameters

Occupational

Health (VA)

14


iEHR -- Presentation Layer





Clinician View (Home Page)

15


iEHR -- Presentation Layer





Clinician View (Patient Summary)

16


iEHR -- Applications and Services

Capability Set 1A

• Pharmacy

o Inpatient & Outpatient Orders Fulfillment

o Inventory Management

o Allergies

o CDS

• Immunization

• Consult & Referral Management

Capability Set 2

• Anatomic Pathology

• Disability Evaluation

• Dental Care

• Credentialing

• Pharmacy

o Barcoding

o Mail Order

• Personal Health Record

• Radiology/Imaging

Capability Sets 3-8

• Patient Portal Infrastructure

• Anesthesia Documentation

• Operating Room Management

• Medical Device Management

• Disease Management

• Disconnected Care

• Business Intelligence

• Patient Questionnaire

• Patient Consent

• Patient Education

• Alerts and Reminders

• Patient Self Report

• DoD/VA Registries

• NCAT (TBI Testing)

• Global Image Access

• Patient Safety Reports

• Teleconsultation

• Document Management

• Blood Management

• Private Sector Data Access

• Nutrition Care

• XML Forms Tool

• Utilization Management

• Genomics

• Encounter Coding

Capability Set 1B

• Care Management

• Emergency Department Care

• Laboratory

• Registration

• Scheduling Appoint

• Documentation

Information Infrastructure

Capability Set 0A

(Enabling Capabilities)

• Identity Management

• Access Control

• Presentation Layer (GUI)

• SSO-CM

• Information Model and

Terminology Services

• Federated Data Repository /

Data Warehouse

• Network and Security

Architecture

• SOA Architecture

FY 11 FY12 FY13 FY14 FY15 FY16 FY17

1.0

In

vestm

en

t

Sets 5-8 Set 4

Set 3 Set 2 Capability Set 1 Initiation

Information Infrastructure Capability Set

Common Graphic User Interface (GUI)

Capability Set 0B

(Common Services)

• Enrollment Eligibility

• Orders Service

• Clinical Decision Support

(CDS)

• Barcoding

• Secure Messaging

o Provider-Provider

o Patient-Provider

Presentation Layer / GUI

Target: 6+capabilities per set

*iEHR Capability Sets

as identified by the ICIB

5 Dec 2011

17


iEHR -- Common Interface Standards

Registries Data

& Services

POINT OF SERVICE

Population Health Data

& Services

EHR Data

& Services

Data

Warehouse

ORGANIZATIONAL INFOSTRUCTURE

Physician/

Provider

Physician/

Provider

Physician/

Provider

Lab Clinician Radiologist Pharmacist Public

Health

Provider

EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP

EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP EHR IP

EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards EHR IP Standards

EHR SCP

Standards

EAI IP

EA

I IP

E

AI

IP

EA

I IP

E

AI

IP

EAI IP EAI IP

EHR IS

EAI IP EAI IP EAI IP EAI IP EAI IP EAI IP ICIB Recommended FOCUS

Architecture Standards

• EHR Svc. Platform Conceptual

Architecture

• EHR Use Cases

• FHIM/EHR Data Model

• EHR-S Services Model

• EHR Interoperability Profiles

• Terminology Standards

• Terminology implemented in data

messaging standards

Implementation Standards

• Patient Registry

• HL7 Provider Registry

• HL7 Pharmacy

• Laboratory

• Public Health Services Standards

• Public Health Surveillance Standards

• Diagnostic Imaging/Teleradiology

• Clinical Messaging

• Technical Standards

Notional iEHR Infostructure: Standards-based Connectivity -- ICIB 11/15

18


iEHR -- Enterprise Service Bus

19

• Facilitates development of

business process-based

common services

• Promotes system interoperability

• Provides enterprise application

integration

• Improves application integration

• Enhances speed to market


iEHR -- Common Data Centers

• September 2011-- Memorandum of Agreement between DoD and VA to consolidate VA data centers into existing Defense Information Systems Agency (DISA) data centers

• By 2015 -- The Departments expect to have consolidated more than 800 data centers

20

Strategy and Goals • Establish core data centers that will support enterprise

applications/services

• Increase mission effectiveness, enhance security, and improve

efficiency across the enterprise


21

Team Approach


Requirements

Clinical

Privacy &

Patient Safety

Patient-centered

Medical

Home/Care

Coordination

Change

Management

Clinical

Specialists

Clinical Quality

Empowered

Patient

The mission of the CIRD is:

To promote safe, efficient and

quality patient care through the

development and implementation

of iEHR capabilities and initiatives

that allow for full interoperability

between the Departments to better

serve Service Members, their

families, and Veterans


iEHR -- Clinically-Driven Solutions

22

CIRD will be comprised of a cross-functional team of clinicians representing VA and DoD organizations

•Continuous flow of information

•Immediate reach within IPO

Benefits to

Clinical

Organizations

Benefits to

Interagency

Program Office

‘

Open Line of Communication

•Regular updates on iEHR progress

•Active two-way communication to IPO leadership about the iEHR

Hands-on Participation in

Requirements Development

•Direct influence on iEHR requirements •Alignment of iEHR requirements with thier beneficiary community

•Side-by-side collaboration between clinical and business communities

•Enhanced information sharing

•Quick access to feedback on pending iEHR clinical decisions

•Support for all iEHR strategic planning

Trusted Requirements

•Active participation from clinical organizations

•Prioritized and rigourously reviewed requirements

Assigned clinicians will serve as a liaison between the IPO and their home organizations

Liaison

23


Real-Time Coordination Collaborative Environment

Direct Access within

Clinical Organizations

Problem Space

24

Requires Unified Strategy and Synchronized Execution at all levels

• Overarching iEHR portfolio being defined

• Functional requirements baseline with bounded scope, capability prioritization, and user stories advancing towards one authoritative product

• Agency modernization strategies being synchronized to a common architecture

• Acquisition policies, life cycle processes, and program execution converging to a single program plan

• Organization/Agency Structures and Investment Strategies are aligning for joint program management and centralized execution

• Enterprise Governance Framework being extended

• Technology assessments and capability enhancement planning moving forward

• Single Organization Structure for agile execution

• Clearly delineated roles and responsibilities

• Joint and synchronized program execution

• Validated Requirements Baseline

• Operationally-adaptive Common Frameworks and Business Processes with Governance Structure, Business Rules, and Reference Architecture

• Federated Development and Test Environment

• Unified approach across all disciplines

• Centralized Investment process

• Standards-based development with implementation compliance

Where we are… Where we are going…

“… full and seamless electronic exchange and record portability of healthcare information in a secure and private format …to ensure … effective delivery of healthcare services.”

DEPSECDEF, DEPSECVA and VCJCS Update on 12 February 12, 2011

Vision…

Deliver affordable, interoperable and time-critical integrated electronic healthcare capability across DoD and VA

PM iEHR Mission…

FY12 Snapshot Accomplishments and Planned Execution

25

Planned Execution

• Capability Execution – Complete Business Requirements Document (BRD) for

Consults Orders Portability for North Chicago – Start establishing the demonstration and test environment – Begin mapping the VA Salt Lake City Health Care System to

the Health Data Dictionary (HDD) – Implement iEHR Single Sign On/Context Management

(SSO/CM) capabilities with JANUS at North Chicago – Evaluate open-standards, open-source portal infrastructure

and portlet interoperability standards and product(s) – Continue VA deployment of Lab capability and complete

DoD Implementation Plan – Perform gap analysis of Pharmacy capability and determine

path forward

• Program Execution – Stand-up the iEHR Program Management Office (PMO), to

include Organization Structure, Staff Profile, and Integrated Product Teams

– Define the bounded iEHR Portfolio – Define a Functional Requirements Baseline (FRB) and

conduct Requirements Review – Establish a Development and Test Environment at

Richmond – Finalize the Acquisition Strategy – Establish Baseline Cost Profile – Define the Transition and Target iEHR Architectures – Define the iEHR Data Strategy – Align program increments with ICIB-defined Capability

priorities

Accomplishments to Date…

• Signed Interagency Program Office Charter, October 27, 2011

• Established an operational Open Source Custodial Agent, October 31, 2011

• Initiated Development Test Center / Environment (DTC/DTE) Configuration

• Deployed early version of iEHR joint presentation layer at North Chicago on December 1, 2011

• Achieved high level definition of Capability Sets 0 and 1 from the DoD/VA Interagency Clinical Informatics Board, December 6, 2011

• Established Capability-Integrated Project Team (CIPT) for Presentation Layer

• Published Requests For Information for Pharmacy, Immunization, and Scheduling capabilities (1QFY12)

• Finalized Health Data Dictionary legal license negotiations to enable Salt Lake City mapping project, January 12, 2012

• Defined the Organization Structure and Staff Profile for the IPO and iEHR Program Management Office (PMO)

• Stood-up iEHR PMO Working Groups / Integrated Product Teams

• Published Request For Information (RFI) for Pharmacy and Immunization

• Applied critical stabilization fixes to DoD current systems, i.e., Clinical Data Repository and Applications

High-level Life Cycle Framework

26

27

Agile Methodology

Summary

• Current EHR efforts continue to focus on speed, availability and usability

• Continuing to share health data with partners to support healthcare delivery for our beneficiaries across the continuum of care

• DoD and VA working together on the next-generation EHR

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